Deadly Causes of Chest Pain

Margarita E. Pena, MD, FACEPSt. John Hospital and Medical Center

Detroit, MI

What are the 6

causes of chest

pain that can kill?

Case

56 yo M with DM, HTN,

and tobacco use

complains of Chest

Pain while in the CDU

Key Initial Evaluation

Gen Appearance (diaphoresis = bad)

Vital Signs (hypotension = bad)

Heart (Muffled? Regular? Fast?)

Lungs (Equal? Wet? Wheezing?)

Extremities (=pulses?, cap refill = bad)

➢Any bad sign = ABC’s and call CDU doc

Key Initial Evaluation*EKG for all ; CXR for most (portable)

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Location: Central, left, or right

Radiation: Back, neck, arm

Assoc symptoms: SOB, nausea

Timing: Gradual or sudden onset

Provocation: What makes worse or better?

Severity: Scale of 1-10

ACS = STEMI

1. ST elevation in 2 contiguous leads (II,III,aVF) with reciprocal ST depression (V1-V3)

2. 1mm in inferior leads, 2mm in anterior leads

Importance of Repeat EKG’s

Repeat EKG every 5-10 min while CP ongoing

Hyperacute T waves is an early and transient EKG finding in early STEMI

Diagnosis?Signs

Tachycardia > 100 beats per minuteTachypnea > 20 bpmHypoxia < 95% on RALungs clearExtremities: equal pulses, +/- unilateral swelling or immobilized or recent injury

SymptomsSOB or dyspnea- Present in 90% Chest pain (pleuritic)- 66% of patients with PECoughSudden onsetGen Appearance: anxious

Pulmonary Embolus

Risk Factors

Hypercoaguability

Malignancy, pregnancy, estrogen use, factor V Leiden,

protein C/S deficiency

Venous stasis

Bedrest > 48 hours, recent hospitalization, long

distance travel

Venous injury

Recent trauma or surgery

PE EKG: Sinus Tachy most frequent

finding; Classic S1,Q3,T3 seen in

PE Diagnosis and Treatment

D-dimer - Sensitive in low to mod probability (A neg

d-dimer = >99% no PE); not sensitive enough for

high probability; Lots of false positives (renal, CA,

aortic dissection)

CTA chest = Gold Standard if mod-high probability

IV fluid to maintain BP

Heparin (limits propagation, doesn’t dissolve clot

Unfractionated or Fractionated (NOAC)

Fibrinolytics (tPA) - if pt is unstable, RV strain

Diagnosis? (tough one)

Signs – BP generally high, but VS variable

Symptoms

Chest or back pain – ripping/tearing in 50%

Neurologic symptoms in 20%

Asymmetric pulses and BP readings L vs. R

Pre-syncope or Syncope

➢ *CP +/- BP AND Neuro symptoms = aortic

dissection until proven otherwise

Aortic Dissection

Risk Factors

Bimodal distribution

Young: Connective tissue (Marfan) or pregnancy

Older: Most commonly > 50 (mean age 63)

Risk factors

Male: 66% of patients

Hypertension: 72% of patients

Connective tissue dis-30% of Marfan’s

Cocaine Use

Syphilis

Aortic Dissection

Diagnosis and Treatment

CXR- Widened mediastinum (not sensitive)

CTangio chest- Very sensitive and specific or TEE

Bedside US – evaluate aorta and look at heart to r/o tamponade

CT surgery early

Blood pressure control

Goal SBP 120-130 mmHg

Beta blockers are first line (Labetalol and Esmolol)

Then can add vasodilators i.e. nitroprusside

Diagnosis?

Signs –VS variable; if severe: tachycardic,

hypotensive and hypoxic, distended neck

veins, tracheal deviation

Symptoms

Pleuritic chest pain - sharp

Decreased breath sounds on one side

Tension PneumothoraxRF, Diagnosis

Trauma (rib fx), iatrogenic (s/p central line

placement, thoracentesis), positive P ventilation

(vent, BiPap), COPD, connective tissue dis

Tension Pneumo TreatmentNeedle decompression, Chest Tube

Diagnosis?

Signs

Tachycardia, hypotension (if severe)

Muffled heart sounds

Lungs clear

Symptoms

SOB or dyspnea

Chest pain (positional)

General appearance = Anxious

Cardiac Tamponade - DiagnosisPericardial friction rub; Kussmaul sign=JVD w/inspiration

CXR - large cardiac sillouette; EKG – tachycardia first, then QRS amplitude (low voltage), then electrical alternans

Beck’s TriadSeen in Acute Tamponade

Risk Factors/EtiologyMalignancy, s/p radiation therapy

Renal failure (uremia)

Pericarditis

Lupus

s/p AMI or cardiac cath or CV surgery

Trauma (usually acute)

Infections – HIV, TB

Cardiac TamponadeTreatment

O2, IVF to increase preload, elevate legs to increase venous return; no NIPPV (Bipap)

STAT bedside echo, pericardiocentesis (bedside if in shock); Cardiology/Cardiothoracic Sx for pericardial window

Diagnosis?Signs

Tachycardia, tachypnea, fever (variable)

Lungs clear

Extremities: equal pulses

Symptoms

Dyspnea, dysphagia

Chest pain (pleuritic)-lower chest, epigastric

Radiation to back (sometimes)

Sudden onset if after protracted vomiting; Gradual onset if after EGD

Esophageal Rupture, RF

Aka Boerhaave Syndrome

Mackler Triad (50%): middle-aged man h/o dietary overindulgence and overconsumption of alcohol + CP/subQ emphysema after recent vomiting/retching

Tear in the esophagus leads to leaking of GI contents into the mediastinum

Inflammation followed by infection cause rapid deterioration, sepsis and death

Risk Factors: Iatrogenic (EGD esp w/dilation), severe retching, trauma, foreign bodies, toxic ingestion

Esophageal RuptureDiagnosis & Treatment

NPO, antibiotics, supportive care, Surgical consult

Small tears managed conservatively

Deadly causes of Chest Pain

Acute Coronary Syndromes

Pulmonary Embolism

Aortic Dissection

Pneumothorax

Cardiac Tamponade

Esophageal Rupture